CQI Toolkit - · PDF fileSample CQI Project Top Worksheet –A1C A. DSMES service’s one or more aggregate participant selected behavioral goal outcome Behavioral Goal Category

Copyright 2017 by American Diabetes Association All rights reserved.
This document or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the American Diabetes Association. Revised per 2017 NSDSMES 9/2017
CQI Toolkit
In this toolkit you will find an explanation of what is required by ADA Recognized DSMES
services to meet the National Standards for Diabetes Self-Management and Support Standard
10s criteria. You will also find a user friendly sample worksheets, templates, and examples.
Contents:
I. Standard 10
II. CQI and Standard 10 Cycle
III. CQI Worksheet
IV. CQI Example A1C
V. CQI Example Exercise
VI. CQI Example LDL
VII. CQI Other Sample Plans

Top
Review Criteria Indicators Yes No N/A
A. The DSME program has a quality improvement process and plan in place for evaluating the education process and program outcomes.
1. There is evidence of aggregation of the following participant outcomes: a. At least one participant behavioral
goal outcome b. At least one other participant
outcome. 2. There is documentation of a Continuous
Quality Improvement (CQI) project which will include: a. Opportunity for DSMES service
improvement or change (what are you trying to improve, fix, or accomplish)
b. Baseline project achievement (new providers may not have a baseline measure at the time of application)
c. Project target outcome d. Outcome assessment and evaluation
schedule.
a
b
c
d
a
b
c
d
B. Quality improvement is based on regular aggregation of program outcomes data and application of results to enhance quality of the DSME and address gaps in service.
1. DSMES service providers will have documentation reflecting an ongoing quality improvement project and implementation of new project when applicable. a. Existing DSMES service providers will
have documented quality improvement project outcomes.
b. Quality improvement outcomes will be measured annually at a minimum.
c. Existing DSMES service providers will have documented plans and actions based on project outcome.
2. improvement project and implementation of new project when applicable. d. Existing DSMES service providers will
have documented quality improvement project outcomes.
e. Quality improvement outcomes will be measured annually at a minimum.
f. Existing DSMES service providers will have documented plans and actions based on project outcome.
a
b
c
a
b
c
Standard Met?
Yes No
Standard #10: Quality improvement
The provider(s) of DSME will measure the effectiveness of the education and support and look for ways to improve any identified gaps in services or service quality using a systematic review of process and outcome data.
Findings / Notes:

Standard 10 Cycle
Aggregated Behavioral Goal
(at least one) At least one
Aggregated Other Participant Outcome
(at least one)
Select one of the above or another DSMES process or
outcome
CQI Project What are you trying to improve, fix or accomplish?
Target Outcome
Aggregated Outcome
Review Outcome versus Target
Review Current Operaations
Amend Current Operations
Implement Amendments Report Cycle
as long as you
continue to work on
this CQI project
Top
p

Top
ACQI Project Worksheet
A. DSMES services one or more aggregate participant selected behavioral goal outcome
Behavioral Goal Category and Aggregated Outcome:
Add more lines if needed.
B. DSMES services or more aggregated other participant outcome
Other Participant Outcome and Aggregated Outcome:
Add more lines if needed.
C. CQI Project
Enter in line below either one of the above aggregated outcomes from A or B above or select another DSMES process or outcome that the CQI project will address.
List below what your CQI project will be trying to improve, fix or accomplish?
D. What is the CQI project outcome target? The % outcome the DSMES service is trying to achieve?
_%
E. Determine the CQI project outcomes reporting and review cycle: monthly, quarterly, bi-annually.
a. Reporting and outcome review cycle will be .
CQI Cycle
F. Aggregate outcomes
G. Review outcomes versus target
H. Review current operations as they relate to the CQI project
I. Amend current operations to improve CQI outcomes
J. Implement improvements
Repeat cycle starting with F.
E) Reporting Review Date
Enter Date to Report/Review
D) CQI Target % % % % F) CQI Outcome % % % % G) Review Outcomes
H) Review current operations and consider amendments
I)List amendments to current operations
J) Date change Implemented

Top
Sample CQI Project Worksheet A1C
A. DSMES services one or more aggregate participant selected behavioral goal outcome
Behavioral Goal Category and Aggregated Outcome: Physical Activity 75%
B. DSMES services one or more aggregated other participant outcome
Other Participant Outcome and Aggregated Outcome: A1C 57%
C. CQI Project
Enter in line below either one of the above aggregated outcomes from A or B above or select another DSMES service process or outcome that the CQI project will address.
A1C
List below what your CQI project will be trying to improve, fix or accomplish?
Increase the number of participants who enter the DSMES service with an A1C above 8 with an A1C less than 7%
D. What is the CQI project target % outcome you are trying to achieve?
85%
Reporting and outcome review cycle will be bi-annually. CQI Cycle
F. Aggregate outcomes
G. Review outcomes versus target
H. Review current operations as they relate to the CQI project
I. Amend current operations to improve CQI outcomes
J. Implement improvements
Repeat cycle starting with F.
E) Reporting Review Date
June 20 Enter Date to Report/Review
December 20_ Enter Date to Report/Review
June 20 Enter Date to Report/Review
December 20_ Enter Date to Report/Review
D) CQI Target 85% 85% 85% 85% F) CQI Outcome
57 % 64% 79% %
G) Review Outcomes
93 of the 163 participants had a post DSMES A1C less than 7%.
H) Review current operations and consider amendments
Currently how often you should have your A1C tested is reviewed during class 4 of the 5 class series.
The participants reported feeling empowered when they learned of different changes that can be made that can impact A1C including medication and behavior/lifestyle changes.
Participants reported feeling hopeful after learning that reducing A1C levels can reduce chances of getting DM complications. Participants ask what BG levels are associated with A1C levels.
I)List amendments to current operations
Add activity to class 1 to help the participants start considering different changes they can make that will positively impact the level of their A1C.
Add content to class 2 discussing the positive impact with each % reduction in A1C level.
Create scale with BG average and A1C scale handout. Participants will be able to track their BG and how it relates to A1C levels.
J) Change date June 4 15, 20 December 2, 20 Jun 12, 20

Top
Sample CQI Project Worksheet Physical Activity
A. Services one or more aggregate participant selected behavioral goal outcome
Behavioral Goal Category and Aggregated Outcome: Physical Activity 40%
B. Services one or more aggregated other participant outcome
Other Participant Outcome and Aggregated Outcome: Hospital Admissions due to diabetes 3%
C. CQI Project
Enter in line below either one of the above aggregated outcomes from A or B above or select another DSMES process or outcome that the CQI project will address.
Physical Activity
List below what your CQI project will be trying to improve fix or accomplish?
Increase the % of DSMES participants who are achieving their physical activity goal.
D. What is the CQI project target % outcome you are trying to achieve?
85%
a. Reporting and outcome review cycle will be quarterly. CQI Cycle
F. A

Documents

CQI Toolkit - · PDF fileSample CQI Project Top Worksheet –A1C A. DSMES service’s one or more aggregate participant selected behavioral goal outcome Behavioral Goal Category